Need-to-know updates featured in articles, news briefs, podcasts, and videos keep everyone in the dermatology community in the vanguard of the effort to put a cure for melanoma within reach.

Melanoma Awareness Month

This online, on-demand virtual symposium brings together renowned experts in dermatology to discuss newer treatments for patients with psoriasis.

Maui Derm Tyk2 Psoriasis Archived Webcast

Patients with this rare and severe skin disorder may soon have a new therapeutic option.

Perspectives on Generalized Pustular Psoriasis

Size, aggressive pathology, recurrence, and site on the body all were linked with an increased number of Mohs micrographic surgery (MMS) stages for patients with basal cell carcinomas (BCC), in a study that was presented this week at the American College of Mohs Surgery (ACMS) 54th annual meeting in Philadelphia, Pennsylvania.

Amit Om, MD, who is the dermatology resident physician at Bennett Surgery Center, presented their group’s data, which was a retrospective analysis of 11 patients and tumor variables and the mean MMS stage number for 1000 consecutive BCCs. The 11 patient variables, according to the abstract, were “gender, internal/external referral, immune status, aggressive pathology, head/neck vs trunk/extremities, AUC location (H, M, L), duration, pre-operative AUC score, and largest pre-operative length.”

The researchers noted that on bivariate analysis some of the variables that were predictive of an increased number of MMS stages for patients with BCCs included: “[BCC] had been treated previously (2.4 vs 1.93, 

 < .0001), location on the head/neck (2.07 vs 1.61, 

 = .0001), location in “H” area as defined by the appropriate use criteria (AUC) (2.17 vs 1.88 vs 1.49, 

 = .0000), pre-operative AUC size “4,” (2.45 vs 2.14 vs 1.98 vs 1.77, 

 = .0000), pre-operative AUC score 7-9 vs 4-6 and 1-3 (2.04 vs 1.46 vs 1.3, 

 = .0000), largest pre-operative length greater than 1.0 cm (2.21 vs 1.88, 

= .0001), aggressive pathology (2.16 vs 1.95, 

 = .0138) and duration greater than or equal to 16 months (2.17 vs 1.97, 

Size, aggressive pathology, recurrence and body site were all statistically significant in multivariate analysis, which allowed their team to create a predictive model of who would go on to develop aggressive BCCs, which can be a powerful tool in deciding treatment approaches, Om said.

“How will this impact your practice?” Om said. “For anyone doing complex tumors, this type of data can protect you…you can use this Mohs data to triage your data.”

Om A. Predictive factors that increase the number of Mohs micrographic surgery stages for basal cell carcinomas. Presented at: American College of Mohs Surgery. May 12-15, 2022. Philadelphia, PA.

Articles

A study presented at the current ACMS meeting highlights variables that could predict BCC, including: gender, immune status, and more. 

Examining These Patient Variables May Help Predict Aggressive Basal Cell Carcinomas 

Whether it be avoiding infection at the surgical site, or a chance for a patient to bleed out, there is no question that seconds matter during any surgical procedure.

At the American College of Mohs Surgery (ACMS) 54th annual meeting being held this week in Philadelphia, Pennsylvania, a group of researchers from Emory University in Atlanta, Georgia, presented a pearl that is designed to help surgeons save those precious seconds during Mohs surgery. The technique that was discussed has applicability to many types of surgical procedures.

Latrice Hogue, MD, set up her presentation with a common problem faced by Mohs surgeons: “You are scrubbed in and need to request assistance—more suture, etc.—from team members who are outside of the room, what do you do?”

Hogue and colleagues noted that many Mohs surgical suites are not equipped with buzzers/buttons to call for assistance, and that often in these scenarios, other people in the room are usually scrubbed in as well and would have to scrub out, which leads to a potential wasting of resources, for example, staff time, and also the risk of contamination of having that person leaving the room. And of course, there is also the potential of lost time, which could lead to a delay in surgical procedure to stop and locate assistance.

To address this potential problem, the Emory team tried out an innovative solution, which is to initiate the “walkie talkie” feature on their digital watch, pull sterile gloves over their digital watch prior to the surgery, and then be empowered to communicate to their teams through this push-to-talk technology.

This has proven a useful tool for their team, Hogue explained, as most team members have these digital watches, just like most of the world.

“Digital watches are currently used by over 100 million people worldwide,” Hogue said, quoting an article from Techradar.com.

The push-to-talk feature on these phones allows the surgeon to communicate via one tap and an immediate voice message to the recipient, and the range for the technology includes anywhere an internet connection is available.

From apps that are designed to prepare patients for their surgeries, to headset use by surgeons in the operating theatre during procedures, technology hacks like the ones offered from Emory are quickly changing the way that patients are treated, and ultimately, helping surgeons perform their jobs in a more timely and safer way.

Hogue L, Lim J, Blalock T, Team communication tool during Mohs surgery. Presented at: American College of Mohs Surgery. Held May 12-15, 2022. Philadelphia, PA.

Presenters highlight the possible solutions to communication between the scrubbed-in surgery team and outside help that could save time. 

Seconds Matter: A Pearl for Improving Communication During Surgery

Community care skin cancer referral times were less timely than Veterans Affairs’ (VA) optimal goal of 28 days for specialty care, in at least 2 tertiary VA care centers in the Midwest and East Coast, according to an abstract presented at the American College of Mohs Surgery meeting being held this week in Philadelphia, Pennsylvania.

Jennifer G. Powers, MD, of the University of Iowa, Dermatology, presented the data, which was based on a retrospective chart review of 175 patients referred by the VA for community care in the Midwest VA System, and 203 in the East Coast VA system between October 1, 2020, and May 15, 2021.

“Skin cancer…affects 4% of VHA patients,” Powers told the audience, with “skin cancer and related damage costing about $366 million or a $60 billion budget.”

Included case patients were identified “using community care [CC] referral logs with ICD-10 diagnoses screened for relevance to skin cancer.” She noted that miles to treatment centers from patient homes varied between the Midwest and East Coast cohort, with average drive times being significantly higher in the Midwest, she said, which obviously could impact uptake of treatment.

Average wait times from referral to appointment date was similar for both groups at about 33 days in the Midwest (n = 71) and 30 days in the East Coast patient cohort, however, time from biopsy to treatment for CC Mohs was very different, from 32.8 days in the Midwest group to 66 days on the East Coast. Powers noted that follow up notes were often incomplete in both groups, in about 15% of cases in the Midwest group and 21% of cases in the East Coast group.

“It’s wonderful that veterans have treatment choices, but it’s also worth looking at the balancing message, which is that sometimes there are miscommunication issues here,” Powers said.

Appropriate use criteria were being followed was common. In 100% of cases in both areas, however, only about 60% of the health care providers were ACMS certified.

Powers said that future study areas could incorporate more VA areas to do a comparison of areas and to hone in on addressing some of the more problematic areas, like missing notes.

Training for CC mohs surgeons did not match that of tertiary VA onsite providers.

Powers JG, Munjal A, Bhate C, et al. Skin in the game: community care management of procedures for skin cancer, a retrospective comparative study at two tertiary veterans affairs centers. Presented at: American College of Mohs Surgery. May 12-15, 2022. Philadelphia, PA.

In a presentation at the current American College of Mohs Surgery meeting, Jennifer G. Powers, MD, highlights the needed improvement for immediate access to skin cancer care for VA patients, noting a 33 day average wait time compared to the VAs optimal goal of 28 days. 

Improvement Needed in Immediate Access to VA Skin Cancer Care in Midwest, East Coast

and joined the MJH Life Sciences team in April 2021. She graduated from Kent State University in 2018 with a bachelor's degree in journalism and a minor in sociology. Linda used to work as a creative writer for 

 and was a technical writer/regulatory specialist/purchasing agent at GM Industrial before coming on to the team. She enjoys reading, traveling, and learning new perspectives. You can reach her at 

POLL: Is Telehealth Helping or Hurting the Dermatology Specialty?

Specifying histologic subtypes can drive better outcomes for patients and improve research.

Are Millennials Facing a Melanoma Upsurge?

With the number of melanoma cases among young adults on the rise, adherence to preventative measures could be critical to stemming the tide of increased incidences of this deadly skin disease.

This week's edition of the Mainstream Patients features stories about treating scars, jojoba oil for skin, and more.

For years, teenagers have been told to avoid certain foods to reduce acne. A review article examines the evidence.

Climate Change: Making Patients Sick and What to do About it?

At the 2022 American College of Obstetricians and Gynecologists Annual Clinical & Scientific Meeting, 4 health care professionals spoke of disease states in both women and children caused by climate change, and what physicians can do to mitigate this crisis.

Study: High Rate of Skin Diseases in Europe

Nonmelanoma skin cancer ranks in the top 12 skin diseases reported.

Racism in Health Care Increases Vaccine Hesitancy in Minority Groups

Study shows that 10% of minorities refused COVID vaccines because of past racial discrimination experiences.

Is rosacea being confused with acne? Are physicians treating the their patients with the patient's expectations in mind? Questions like these are more are answered by Adebola Dele-Michael, MD.

Launch: VialConnect CTMS with Patient Recruitment Assistance

VialConnect is a clinical trials management system built for coordinators and investigators.

A look at the common condition and how to treat it.

Program Helps Female Physicians Avoid Burnout

Online conferencing, messages, become tools against burnout, imposter syndrome.

Pointers with Dr Portela: Sunscreen Shorts

In this week’s Pointers with Dr Portela, the 208SkinDoc has posted serval YouTube shorts on sunscreen. See what pearls he had to share on protecting skin from the sun.

Teenagers were the most likely to be affected by targeted misinformation.

How a digital front door can improve patients’ access to care

Online-first engagement ensures patients obtain the right care for their specific needs.

Inflation Rate Slows, but Prices Still on the Increase

Latest numbers show prices rose at a slightly slower pace in April.

What’s Happening at the 2022 ACMS Meeting?

Starting today, the American College of Mohs Surgery is having their 54th Annual Meeting in Philadelphia, Pennsylvania.

Surgical site infections (SSIs) are a common adverse event after Mohs Micrographic Surgery, but researchers aimed to find out how the clinical features of gram-negative differ from their counterparts.

Mitigate Malpractice Risk from Key Litigation Drivers

Dermatology has enjoyed one of the lowest litigation rates among medical specialties, but recent findings presented at the 2022 American College of Mohs Surgery Annual Meeting caution that mounting risks relating to procedural dermatology and cutaneous oncology could change that.

Bacterial Colonization After Mohs Surgery

A poster at the 2022 American College of Mohs Surgery Annual Meeting examined the prevalence of bacterial organism colonization in Mohs wounds left to secondary intention.

ICYMI, this week we had stories from the 2022 American College of Mohs Surgery Annual Meeting, a potential melanoma surge, and more.

The Weekly Roundup: May 9-13

Mohs Micrographic Surgery (MMS) can be conducted on several parts of the body, including places that the skin does not have much laxity like the legs. When this surgery is conducted in lower leg area, many times dermatologic surgeons will leave the wounds to heal by second intention, but there is evidence that these wounds are at a higher risk for infection.

A poster at the 2022 American College of Mohs Surgery Annual Meeting being held May 12 to 15, 2022 in Philadelphia, Pennsylvania, investigated the likelihood of this complication, to provide evidence-based research to help guide antibiotic treatment. The findings from a prospective, controlled trial compared the bacteria colonizing in second intention lower leg wounds at a single academic procedural dermatology office.

Lower legs can be particularly hard to make an infection diagnosis, the poster stated, as both pain and erythema surrounding these wounds plus poor circulations and venous congestion make it difficult. This can lead to unnecessary antibiotic treatments. Patients included in the trial had to have undergone MMS for lesions below the knee and were at their 2-week follow-up visit. At this visit, the wounds were swabbed for bacteria and patients were then categorized into infected or control groups based on the evidence of erythema, pain, swelling, and warmth.

These swabs were sent to Cooper University Hospital microbiology lab in Camden, New Jersey, for culture tests and were then recorded by bacteria colonization if any was present. In total, 51 patients were studied between November 2017 and July 2020. Of this number, 15 were infected wounds and 26 were control.

Cultures grew from 11 (21.6%) from normal skin flora alone, 8 (15.7%) from clinically infected wounds, and 3 (5.9%) from control wounds (

= .02). It was found that a higher rate of 

Coagulase-Negative Staphylococcus (CoNS) 

 colonization for the control group wounds versus the infected wounds (

) at 25.4% (n=13) was the most common pathogen found in culture. When broken down, 15.7% were in infected wounds and 9.8% in control wounds (

= .73). Of this total, 25.4% or 4 wounds, all from the infected group, were 

Methicillin-resistant Staphylococcus aureus (MRSA)

in 11 wounds, 6 control, and 5 clinically infected. With this data, no significant correlation were identified between colonizing bacteria and wound location, wound size, stage number, type of cutaneous malignancy, or comorbid conditions, according to investigators.

The authors hypothesized that the increase of 

may provide a protective role for wounds instead of an pathogenic once. More research is needed on the subject to determine true correlation, they wrote.

Renzi M, Jennings T, Lawrence N, et al. Assessment of bacterial organism colonizing Mohs surgical wound healing by second intention. Presented at: American College of Mohs Surgery Annual Meeting; May 12-15, 2022; Philadelphia, Pennsylvania

Brianna Castillo, MD, of the University of Missouri in Columbia, and colleagues presented abstract data demonstrating the potential for adjuvant tranexamic acid (TXA) to reduce postoperative bleeding in granulating surgical wounds at the 2022 American College of Mohs Surgery Annual Meeting. Researchers performed a double-blind randomized controlled trial on the effectiveness of TXA in preventing bleeding in granulating surgical wounds. TXA is a drug that prevents blood clots from breaking down.

“Postoperative bleeding is one of the more common complications when a wound is healing by second intent and can lead to patient distress and unnecessary return visits including possibly to emergency rooms after hours, thus generating increased cost to patients in the form of copays for emergency care,” the researchers wrote.

According to Castillo and colleagues, TXA topical use can decrease intraoperative and postoperative bleeding in maxillofacial, orthopedic, and plastic surgeries It has been used as a topical hemostatic agent for superficial oral trauma and in anterior epistaxis, as well.

The study enrolled 124 patients between October 1, 2020 and December 30, 2021. Each group had 62 patients. The study group consisted of patients with surgical defects that had a wound to heal who received 25mg/ml TXA-soaked pad, while the control group received a placebo of a saline-soaked pad. Both groups received  standard petrolatum gauze pressure dressing overtop.

Researchers gave patients wound care instructions and information on when to call their provider about bleeding questions. Patients received follow-up calls after 3 days to answer postoperative bleeding questions and to report any symptoms related to TXA treatment.

The study authors said no bleeding was reported in the TXA group that required patients to reference the provided wound care instructions or to call a provider, while the placebo group had 6 patients (9.7%) report bleeding within 48 hours after their surgeries.

Researchers reported this as statistically significant, with a p-value of 0.028. There were no reports of perceived adverse effects among the 124 study participants.

“TXE is an inexpensive and easy topical preventative measure to consider adding to the wound care of granulating defects in the surgical setting. We have implemented this in our practice at the University of Missouri,” Castillo said at the conclusion of the presentation.

Castillo and her colleagues reported no relevant financial disclosures.

Castillo B, Anokhin A, Golda N. Randomized trial of topical tranexamic acid as wound care adjunct for hemostasis of granulating wounds in the setting of Mohs micrographic surgery. Presented at: 2022 American College of Mohs Surgery Annual Meeting; May 12-15, 2022; Philadelphia, Pennsylvania.

Topical tranexamic acid is an effective wound care adjunct in reducing rates of postoperative bleeding of granulating defects in Mohs micrographic surgical settings.

Topical Tranexamic Acid Shows Efficacy for Postoperative Bleeding Reduction

Shoshana R Blumenthal, MD, who is a dermatology resident the University of Minnesota at Minneapolis, and colleagues presented the clinical abstract of retrospective study on single-stage periosteal flap techniques at the 2022 American College of Mohs Surgery Annual Meeting.

Two dermatologic surgeons performed eyelid reconstruction surgeries on 7 patients (5 men and 2 women; mean age 58 years). The procedures were performed at a single academic center between January 2017 and December 2021. Researchers reviewed patient demographics, operative notes, and follow-up notes; 2 cosmetic dermatologists examined follow-up photos for 6 of the 7 patients and used a visual analog scale.

 Blumenthal and colleagues reported that all tumors had been basal cell carcinoma and had a mean defect area of 6.03 cm

Researchers reported successful results, with all cases resulting in adequate surgical and cosmetic outcomes, Blumenthal noted during the presentation. The mean cosmetic score was 84.6 +/- 14.6, and there were no serious post-operative interventions or complications for patients.

Two of the patients had minor complications, and Blumenthal said during the presentation that this rate of less than 30% was comparable to those reported in ophthalmology series. Researchers reported that 1 female patient had “medial and lateral canthal webbing and slight scleral show which she opted to address conservatively, and one patient who experienced mild-to-moderate lagophthalmos and mild lower lid ectropion.”

 Blumenthal said at the presentation that there was “a correlation between defect size and complications, as well as defect size and a lower cosmetic score.”

Single-stage periosteal flap surgery can prevent patients from enduring traditional two-stage flaps that leave them with monocular vision, according to researchers. 

"The horizontal component averaged 2.4 cm, which makes these cases particularly challenging," Blumenthal said. "Typically, this would have necessitated the 2-stage Hughes procedure."

“Additionally, unlike the classic lateral periosteal flap where the lateral canthal remnant is discarded, we demonstrated the utility of retaining the lateral tarsal remnant, releasing it with a full-thickness incision through mucosa, allowing its medialization, and thereby maximizing native tarsus and lashes,” Blumenthal and colleagues wrote.

Blumenthal said that Mohs surgeons can successfully and safely execute periosteal flaps to reconstruct large, full-thickness eyelid defects. “The potential benefits to these patients include fewer visits to a single provider, avoidance of general anesthesia, and preservation of monocular vision,” Blumenthal said at the conclusion of the presentation.

1. Blumenthal SR, Knabel D, Mori W, et al. Posterior lamella reconstruction by periosteal flap: a retrospective review. Presented at: 2022 American College of Mohs Surgery Annual Meeting; May 12-15, 2022, Philadelphia, Pennsylvania.

Single-stage periosteal flap technique to treat full-thickness eyelid defects is safe, effective, and aesthetically acceptable, according to a study presented at the 2022 American College of Mohs Surgery Annual Meeting on May 12, 2022.

Periosteal Flap Safety, Effectiveness, and Aesthetic Quality in Posterior Lamella Reconstruction

Innovations in the way health care is delivered that are being spearheaded largely by physicians at the beginning of their career coming into the field should provide hope for the future of medicine, according to a speaker at the 2022 American College of Mohs Surgery Annual Meeting being held May 12 to 15 in Philadelphia, Pennsylvania.

In a keynote session, Marty Makary, MD, MPH, surgeon and public policy researcher at Johns Hopkins Medicine, in Baltimore, Maryland, told the audience that these innovations will mean a systemwide change in how health care will be delivered.

“’Holistic care’ doesn’t capture it, ‘precision medicine’ doesn’t capture it,” Makary said, noting these phrases are not enough to describe some of the changes that are being talked about in medical schools and by the physicians joining the profession. “They are asking ‘should we be treating more patients with diabetes with cooking classes as opposed to medicine,’ ‘should we be talking about school lunch programs as much as we talk about bariatric surgery,’’ should we be treating more high blood pressure patients with stress management instead of throwing antihypertensives at them’?”

These solutions are needed, he said, because our current health care system is in crisis. He boiled the current health care crisis down to 2 central drivers, specifically appropriateness of care and pricing failures that are creating an open door for a “middle-man industry,” that is setting prices and making it difficult to deliver quality care at a price that is manageable for most patients.

As an example of inappropriate care, Makary pointed to the numerous studies that exist about antibiotic management being sufficient to manage about two-thirds of appendectomy cases, and yet this surgery is routinely done.

 “Our European surgeon colleagues are laughing at us, saying ‘we’ve been doing [antibiotic treatment] for decades, yet adoption is slow’ here,” he said.

In another example, Makary said it has been routine practice for some time to recommend daily low-dose aspirin to prevent cardiovascular disease. He said recently released recommendations from the US Preventive Services Task Force now reverse this recommendation in adults ages 60 and over.

 He said growing evidence has shown that this practice may lead to gastrointestinal issues and potential strokes, and getting this information is what he said needs to be done to hone in on appropriate care targets. “The best way to lower drug prices in the United States is to stop taking medicines we don’t need,” he said.

Addressing price points, Makary said that health care cost problems are systemic, even reaching as far as the National Institutes of Health (NNIH). “In 2020, NIH spent 2.2 more times on aging research that we did on COVID-19 research,” Makary said. “Now look, I’m all for research into aging, but not during a pandemic.”

Another issue is the pricing of the medications themselves. One need only look at their local pharmacies to see huge differences in the prices of medications that patients use every day to witness the systemic problems of pricing in health care, and that’s not even taking into account the differences in insurance payments and reimbursement structures.

So, what’s the answer to this crisis? Makary said it’s going to take a shift in the way that medicine is delivered. And the good news is that these changes are coming, he said.

“Social justice is a generational value,” in those graduating from medical school, Makary said, and that, he continued, will likely yield a better future ahead.

Makary M. The grassroots movement to redesign healthcare – preparing for the future of medicine. Presented at: 2022 American College of Mohs Surgery Annual Meeting; Philadelphia,May 12-15, 2022.

A randomized trial comparing antibiotics with appendectomy for appendicitis. 

. 2020;383(20):1907-1919. doi:10.1056/NEJMoa2014320

US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin use to prevent cardiovascular disease: us preventive services task force recommendation statement. 

. 2022;327(16):1577. doi:10.1001/jama.2022.4983

Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC) Report. Accessed May 13, 2022. https://report.nih.gov/funding/categorical-spending#/

Marty Makary, MD, MPH, predicts systemwide change in the world of health care. 

Hope for the Future: Innovative Physicians Changing the Way Health Care Delivered 

John Jesitus is a medical writer based in Westminster, CO.

Key directions for melanoma treatments under development include treating tumors in the perioperative period and addressing unresectable tumors, according to a review published in 

Oral and Maxillofacial Surgery Clinics of North America.

1 This rapidly evolving environment will require physicians to monitor evolving care standards and embrace multidisciplinary teamwork, authors added.

“Even though we’ve had profound success in terms of melanomas treatment in the last 10 years, we’ve also seen a cemetery of failed ideas and failed treatments, most of which involve the immune system,” corresponding author James R. Nitzkorski, MD, told 

. He is a surgical oncologist and director of the surgical residency training program at Nuvance Health, Vassar Brothers Medical Center, in Poughkeepsie, New York.

Perhaps the most promising avenue for future melanoma treatments, he said, involves patients who have undergone resection of local or regional disease that could be cured with surgery alone. “As a surgeon, my practice is full of patients like this. There is no evidence of disease. They are in remission. But we know that melanoma can be unpredictable, and some of these patients will end up developing recurrence. Is there anything better than we are doing right now in terms of improving their survival?”

In that regard, an important shift toward administering immunotherapy to higher-risk stage II patients has occurred in recent years. For example, the Keynote-716 phase 3 trial showed that adjuvant pembrolizumab (Keytruda; Merck) for up to one year significantly reduced the risk of disease recurrence or death versus placebo in patients with stage IIB or IIC melanoma.2

The following trials have provided encouraging results for neoadjuvant therapy:

OpACIN-neo (NCT02977052)—In this phase 2 trial, neoadjuvant ipilimumab (Yervoy; Bristol Myers Squibb) plus nivolumab(Opdivo, Bristol Myers Squibb) produced pathologic complete response in 77% of treated patients with stage III melanoma metastatic to lymph nodes. Side effects were tolerable.3

PRADO—This OpACIN-neo extension suggests that carefully chosen patients with robust responses to preoperative combination therapy may be able to avoid therapeutic lymph node dissection.4

Additionally, small studies have shown the following:

Preoperative pembrolizumab produced complete or near-complete response in almost 30% of patients with stage III/IV melanoma.5

Among patients with BRAF-mutated melanoma, 25% treated with neoadjuvant dabrafenib and trametinib achieved significantly longer event-free survival versus standard care (surgery plus consideration of adjuvant therapy).6

When Nitzkorski began his surgical oncology practice, only patients with advanced melanoma were referred for immunotherapy. “Now we’re referring adjuvant patients, and even stage II patients, for immunotherapy. The higher-risk stage II patients—stage IIb and IIc—are now eligible in certain circumstances to receive adjuvant therapy. So we are referring many more patients with melanoma to medical oncology to have this discussion.”

For unresectable melanomas, promising intralesional therapies include the following:

Talimogene laherparepvec (T-VEC; Imlygic, Amgen)—This attenuated herpes simplex virus (containing the granulocyte macrophage colony-stimulating factor/GM-CSF) has shown efficacy in phase 3 and in combination with ipilimumab.7,8 But a phase 2 trial in combination with pembrolizumab was terminated.9

Tavokinogene telseplasmid (TAVO, OncoSec)—Anecdotally, Nitzkorski used this treatment under an expanded-access FDA protocol to treat a female with very worrisome advanced melanoma that had spread to multiple lymph nodes and vital organs. “I would estimate that she had weeks to live, and after receiving this treatment, she lived for a year and a half. That’s extraordinary. With just TAVO treatment, all of the regions responded.”

The trend toward multimodal management of melanoma means that patient care is increasingly being provided by multidisciplinary teams. “Melanoma is such a rapidly changing science that unfortunately, what could happen, especially if a surgeon is not routinely caring for melanoma patients, is that the surgeon or physician may have a slightly outdated understanding of the standard of care,” said Nitzkorski. “Because the science is evolving so rapidly, somebody that perhaps was untreatable 5 years ago may have a reasonably good option at this point. So, it is always best for patient care to work in a collaborative environment with other specialists or tumor boards, even if just via phone call.”

Nitzkorski added that in New York’s Hudson Valley, where he practices, surgical oncologists collaborate with local dermatologists to diagnose melanoma. “The surgical oncologist is usually the first person to see patients with melanoma. We’ll work patients up, stage them as necessary, and if necessary, have them be seen by other specialists like medical oncology, genetics, or radiation oncology. We can help facilitate a patient-centered approach to their care.”

The continued pace of melanoma advancements will require physicians to stay on their toes. “Having at least a general understanding of some of the advances that are occurring is going to be necessary for surgeons, dermatologists, and even primary care,” he said. The growing role of gene expression profiling (GEP) provides a timely example.

“At the time of diagnosis,” Nitzkorski explained, “it is now possible to use gene expression profiling with a new melanoma patient to help stratify the risk of developing future metastasis or recurrence. These tests are new, with evolving and maturing data.” As such, he said, if and when to use GEP remains somewhat controversial. “It is starting already. This major push towards more personalized care is already happening.”

Nitzkorski reports no relevant financial interests.

1. Wells K, Anandarajan V, Nitzkorski J. Future Treatments in Melanoma. 

. 2022;34(2):325-331. doi:10.1016/j.coms.2021.11.003

2. Luke JJ, Rutkowski P, Queirolo P, et al. Pembrolizumab versus placebo as adjuvant therapy in completely resected stage IIB or IIC melanoma (KEYNOTE-716): a randomised, double-blind, phase 3 trial. 

. 2022;399(10336):1718-1729. doi:10.1016/S0140-6736(22)00562-1

3. Rozeman EA, Menzies AM, van Akkooi ACJ, et al. Identification of the optimal combination dosing schedule of neoadjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma (OpACIN-neo): a multicentre, phase 2, randomised, controlled trial. 

. 2019;20(7):948-960. doi:10.1016/S1470-2045(19)30151-2

4. Blank CU, Reijers ILM, Pennington T, et al. First safety and efficacy results of PRADO: a phase II study of personalized response-driven surgery and adjuvant therapy after neoadjuvant ipilimumab (IPI) and nivolumab (NIVO) in resectable stage III melanoma. 

. 38(15 Suppl). Abstract 10002. Published online May 25, 2020. https://ascopubs.org/doi/abs/10.1200/JCO.2020.38.15_suppl.10002

5. Huang AC, Orlowski RJ, Xu X, et al. A single dose of neoadjuvant PD-1 blockade predicts clinical outcomes in resectable melanoma. 

. 2019;25(3):454-461. doi:10.1038/s41591-019-0357-y

6. Amaria RN, Prieto PA, Tetzlaff MT, et al. Neoadjuvant plus adjuvant dabrafenib and trametinib versus standard of care in patients with high-risk, surgically resectable melanoma: a single-centre, open-label, randomised, phase 2 trial. 

. 2018;19(2):181-193. doi:10.1016/S1470-2045(18)30015-9

7. Andtbacka RHI, Collichio F, Harrington KJ, et al. Final analyses of OPTiM: a randomized phase III trial of talimogene laherparepvec versus granulocyte-macrophage colony-stimulating factor in unresectable stage III-IV melanoma. 

. 2019;7(1):145. Published 2019 Jun 6. doi:10.1186/s40425-019-0623-z

8. Puzanov I, Milhem MM, Minor D, et al. Talimogene laherparepvec in combination with ipilimumab in previously untreated, unresectable stage IIIB-IV melanoma 

. 2016;34(22):2619-2626. doi:10.1200/JCO.2016.67.1529

9. Amgen. Pembrolizumab with or without talimogene laherparepvec or talimogene laherparepvec placebo in unresected melanoma (KEYNOTE-034). ClinicalTrials.gov identifier: NCT02263508. Updated December 2, 2021. Accessed May 12, 2022. https://clinicaltrials.gov/ct2/show/NCT02263508

Immunotherapy, intralesional treatments, multidisciplinary care teams define rapidly-evolving multimodal approach.

What’s Ahead for Melanoma Management

Close to 5% of patients with chronic lymphocytic leukemia (CLL) have underlying issues like thrombocytopenia, and because a side effect of ibrutinib is an increased risk of clinically significant bleeding, Mohs surgeons may want to consider holding ibrutinib in these patients, according to a presentation at the American College of Mohs Surgery, being held in Philadelphia, Pennsylvania, this week.

Kelsey E. Hirotsu, MD, from the University of California San Diego, reported these conclusions, which were based on a decade-long retrospective study—from July 2011 to June of 2021—of 362 patients who had been diagnosed with CLL and who underwent Mohs.

The team noted about an eleventh of their patient population, or 32 patients, had a post-surgical complication, including bleeding, dehiscence, and infection.

“Cases where patients were on ibrutinib had the most complications, all of which were related to bleeding. There were 43 cases on ibrutinib, 53 cases on a blood thinner (and no CLL medication), and 93 cases on no medications (no blood thinner nor CLL medication), which accounted for 26 complications; 6 complications occurred in cases on CLL medications other than ibrutinib,” Hirotsu noted in an abstract presented at the meeting. Of the dozen or so that experienced complications, 7 noted no complications once they were taken off the study medication.

“The bleeding risk is likely due to inhibiting platelet activation and drug-induced thrombocytopenia,” Hirotsu said during the presentation, but she said, since dose medication or interruption of medication didn’t appear to impact outcome, it may be best to hold this medication in some of these patients.

Hirotsu KE, Loh TY, Zhang S. Post-operative complications in chronic lymphocytic leukemia patients undergoing Mohs surgery: increased risk of bleeding-related complications from ibrutinib Presented at: American College of Mohs Surgery. May 12-15, 2022. Philadelphia, PA.

At the current ACMS meeting, Kelsey E. Hirotsu, MD, discussed the bleeding complications seen in patients on ibrutinib for CLL.

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